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North Bristol NHS Trust
INTEGRATED
PERFORMANCE REPORT July 2019 (presenting June 2019 data)
CONTENTS
CQC Domain / Report Section Sponsor / sPage
Number
Chief Operating Officer
Medical Director
Interim Director of Nursing
Director of People and Transformation
Director of Finance
Responsiveness Chief Operating Officer 13
Medical Director
Interim Director of Nursing
Quality Experience Interim Director of Nursing 38
Research and Innovation Medical Director 44
Facilities Director of Facilities 45
Director of People and Transformation
Medical Director
Interim Director of Nursing
Finance Director of Finance 57
Regulatory View Chief Executive 62
Performance Dashboard and Summaries
Safety and Effectiveness
5
25
47Well Led
REPORT KEY
Unless noted on each graph, all data shown is for period up to,
and including, 30 June 2019.
All data included is correct at the time of publication.
Please note that subsequent validation by clinical teams can alter
scores retrospectively.
NBT Quality Priorities 2019/20
QP1 Supporting patients to get better faster and more
safely
QP2 Meeting the identified needs of patients with
Learning Disabilities /Autism
QP3 Improving our response to deteriorating patients
QP4 Learning & improving from Patient & Carer feedback
(e.g. FFT, complaints, compliments, surveys)
QP5
Learning & improving from statutory & regulatory
quality systems (e.g. incidents, mortality reviews,
inquests, legal claims, audits)
Abbreviation Glossary
ASCR Anaesthetics, Surgery, Critical Care and Renal
CCS Core Clinical Services
CEO Chief Executive
Clin Gov
GRR
Clinical Governance
Governance Risk Rating
HoN Head of Nursing
IMandT Information Management
Med Medicine
NMSK Neurosciences and Musculoskeletal
Non-Cons Non-Consultant
Ops Operations
RAP Remedial Action Plan
RCA Root Cause Analysis
WCH Women and Children's Health
MDT Multi-disciplinary Team
PTL Patient Tracking List
Target lines
Improvement trajectories
Performance improved
Performance maintained
Performance worsened
Upper Quartile
Lower Quartile
5
4
6
5
4
6
EXECUTIVE SUMMARY
June 2019 ACCESS
• In June we experienced a decline in the 4 hour urgent care standard at 72.53% and have underachieved against the Trust’s trajectory of 89.23%. The Trust
had 8041 attendances, which is a 4% increase compared to June 2018. The Trust reported one >12 hour trolley breach in June during a period of Internal Critical
Incident, which was declared following 3 days of high attendances and admissions. 75% of breaches were due to waits for assessment within the ED.
• The Trust has underachieved against trajectory for Referral To Treatment (RTT) incomplete performance for June (85.03% vs trajectory of 87.60%). The total
incomplete waiting list was 28590 against a trajectory of 28148. The Trust has not achieved its trajectory for the number of patients waiting greater than 52 weeks
from Referral to Treatment (RTT) in June (17 vs trajectory of 6). The majority of breaches are within MSK sub-specialties.
• In June, the Trust did not deliver the diagnostic waiting time trajectory of 6.00% with a final position of 6.84%. Plans are in place to work towards improving the
Endoscopy demand and capacity imbalance and full backlog clearance of Urodynamics breaches.
• The Trust has delivered two of the seven national cancer targets in May– The 31 Day Subsequent Drug Treatment standard is achieved at 100% and patients
treated within 62 days of screening, achieving 91.8%. The Trust’s Two Week Wait performance was 83.4% in May (standard 93%), Two Week Wait for Breast
Symptoms declined to 88.8% (standard 93%), 31 Day First Treatment has declined to 88.2% (standard 96%), 31 Day subsequent Surgery has improved to 82.5%
(standard 94%), while the 62 Day Treatment standard reports a marginal underachievement at 78.9% (standard 85%). NHS Digital have acknowledged that there is
an error in the 62 day reporting system nationally which they are working to address. Internal performance monitoring demonstrates performance should be 81.22%
• The Trust exceeded performance against the improvement trajectories for 31 day Subsequent Surgery, 31 day Subsequent Drug Treatment and 62 day Screening.
The Trust failed to meet the improvement trajectory for Two Week Wait, Two Week Wait Breast Symptoms, 62 day GP Referral and 31 day First Treatment. The Trust
improvement trajectory had forecasted recovery against all standards except Two Week Wait by October 2019. The timeframe for meeting 62 day GP Referral, 31 day
First Treatment and 31 day Subsequent Surgery has been revised to December 2019 due to the timeframe for recruiting new staff. Forecasted recovery against the
Two Week Wait standard remains as March 2020.
SAFETY
• A 30% reduction of Grade 2 pressure ulcer incidence is a focus of 2019/20 safety improvement work. In June there were 31 Grade 2 and no Grade 3 or Grade 4
pressure injuries reported. A presentation has been commissioned for the July meeting to provide an understanding of the current position and assurance about the
improvement actions being taken. There were three serious incidents reported and no Never Events declared in June, with the last reported Never Event being 26
January 2019. Patient falls have remained below the national average and infection rates continue to achieve trajectory.
PATIENT EXPERIENCE
• The number of overdue complaints was 20 in June. The number of complaints received in month has reduced further in June from 56 (May) to 52. Maternity
sustained a high percentage of patients (97%) who would recommend the service to friends and family.
WORKFORCE
• The overall sickness levels within the workforce remains at 4.3% compared to 4.4% last year and 4.5% nationally (Feb 2019). The OneNBT Leadership
Programme is at 92% of its target of 350 staff signing up for the programme. Mandatory and Statutory training compliance is above target at 90%. Appraisal
completion rate is lower than target in month. The overall picture on turnover and stability continues to show positive movement. There was a small increase in
vacancy factor due to increases in establishment particularly in genetics. The Band 5 nursing starters are 13.2 wte behind target but it is anticipated the gap will be
bridged throughout the year with the total 2019/20 starters target still being achieved.
FINANCE
• The Trust has a planned deficit of £4.9m for the year in line with the agreed control total with NHS Improvement. At the end of June, the Trust reported a deficit of
£3.4m which is £0.1m favourable to the planned deficit. The Trust has a 2019/20 savings target of £25m, of which £1m of £4.2m was achieved at the end of June.
The Trust financial risk rating on the NHSI scale is 3 out of 4.
National** Rank*** Quartile
QP1 95% 77.15% 93/119 76.16% 72.53% 89.23% 6QP1 0 0 1 5
100% 93.94% 93.70% 95.23% 6100% 99.39% 98.90% 100% 6
0 0 4 0 592% *86.86% 126/177 85.14% 85.03% 87.60% 6
29179 28590 28148 66 13 14 50 2 1 60 0 1 50 1 1 4
1% *4.08% 142/204 5.48% 6.84% 6.00% 50.8% 1.33% 0.79% 6
0 1 2 5QP1 95% 96.21% 95.21% 6
341 326 6QP1 3.50% 7.07% 6.07% 6
0 0 0 484.08% 84.13% 5
93% 90.79% 130/145 84.70% 83.44% 91.23% 693% 78.94% 75/114 89.83% 88.83% 89.60% 696% 95.97% 114/123 93.08% 88.24% 93.98% 694% 92.15% 47/57 80.77% 82.52% 74.31% 598% 99.31% 1/31 100% 100% 100% 485% 77.45% 66/138 84.40% 78.95% 83.93% 690% 87.44% 24/73 93.33% 91.84% 85.29% 6
Previous
month's
performance
IPR
sectionTarget
June-19
Key Operational Standards Dashboard
52WW
Diagnostic DM01 - % waiting more than 6 weeks
Other
Patients treated within 62 days of screening
Patients receiving first treatment within 62 days of urgent GP referral
Res
po
nsi
ven
ess
- C
ance
r
(In
arr
ears
)
Patients waiting less than 31 days for subsequent drug treatment
Patients waiting less than 31 days for subsequent surgery
Patients receiving first treatment within 31 days of cancer diagnosis
Patients with breast symptoms seen by specialist within 2 weeks
Re
sp
on
siv
en
es
s
Patients seen within 2 weeks of urgent GP referral
Ambulance Handovers Within 15 minutes
Ambulance Handovers Within 30 minutes
Ambulance Handovers Within 60 minutes
28 day re-booking breach
Same day - non-clinical reasons
Urology
Plastic Surgery
MSK
Referral to Treatment - Total Incomplete Pathways
ED 4 Hour Performance
12 Hour Trolley Waits
Referral to Treatment - % Incomplete Pathways 7 days : Snapshot as at month end)
Cancelled
Operations
Electronic Discharge Summaries
Mixed Sex Accomodation
Performance
direction of
travel from last
month
Performance
against NBT
Trajectory
Performance
against Target
Access Standard
6
Description
Benchmarking (*month in arrears)
National** Rank*** Quartile
Performance
direction of
travel from last
month
Performance
against NBT
Trajectory
Performance
against Target
Access Standard
Description
Benchmarking (*month in arrears) Previous
month's
performance
IPR
sectionTarget
June-19
Key Operational Standards Dashboard
0 0 0 495% 97.70% 97.00% 695% 96.00% 98.00% 5
27 31 50 0 40 0 40 0 42 5 53 5 51 1 4
95% 95.89% 95.55% 6
E. Coli
Venous Thromboembolism Screening (In arrears)
Hand Hygiene Compliance
MSSA
Grade 3
Grade 2
Never Event Occurrence by Month
Qu
alit
y P
atie
nt
Safe
ty a
nd
Eff
ecti
ven
ess
Pressure Injuries
Grade 4
WHO Checklist Compliance
MRSA
C. Difficile
National** Rank*** Quartile
Performance
direction of
travel from last
month
Performance
against NBT
Trajectory
Performance
against Target
Access Standard
Description
Benchmarking (*month in arrears) Previous
month's
performance
IPR
sectionTarget
June-19
Key Operational Standards Dashboard
Emergency Department QP2 *12.06% 37/136 19.39% 20.56% 15.00% 5Inpatient QP2 *24.82% 154/165 17.58% 17.40% 30.00% 6Outpatient QP2 18.54% 11.74% 6.00% 6Maternity (Birth) QP2 *19.66% 52/125 20.17% 21.05% 15.00% 5Emergency Department QP2 *85.58% 77/132 88.26% 88.01% 6Inpatient QP2 *95.90% 134/158 92.64% 92.82% 5Outpatient QP2 *93.72% 108/202 95.44% 95.63% 5Maternity (Birth) QP2 *97.08% 22/71 97.94% 96.74% 6% Overall Response Compliance QP2 33.00% 71.00% 5Overdue QP2 25 20 6
£734 £1,136 £1,305 59.50% 10.12% 10.79% 515.50% 15.24% 15.47% 54.10% 4.26% 4.27% 585.00% 88.34% 89.77% 511.90% 6.50% 12.01% 5£4.9m2019/20
£1.5 £3.4 £3.2
3 3 4Fin
ance
NHSI Trust Rating
Deficit (£m)
Non - Medical Annual Appraisal Compliance
Trust Mandatory Training Compliance
In Month Sickness Absence (In arrears)
Turnover (Rolling 12 Months)
Month End Vacancy Factor
Agency Expenditure ('000s)
Wel
l Led
Complaints
Qu
alit
y Ex
per
ien
ce
FFT - Response
Rates
FFT - % Would
recommend
RESPONSIVENESS
SRO: Chief Operating Officer
Overview Urgent Care
The Trust reports a decline of the 4 hour urgent care standard at 72.53% in June and continues to underachieve against the Trust trajectory of 89.23%. The 4
hour target remained challenged by high volumes of attendances overall. A period of lower attendances mid-month delivered an improved period of performance,
but this was not able to be sustained, particularly in the latter part of the month where significant increases in attendances were experienced.
Planned Care
Referral to Treatment (RTT) - In month, the Trust underachieved against the RTT trajectory of 87.60%, with actual performance at 85.03%. The total waiting list
reports a position of 28,590, underachieving against a trajectory of 28,148, but is a reduction in the wait list reported in May following targeted data quality work.
The remaining increase in waiting list is a combination of reduced activity and increased demand. The number of patients exceeding 52 week waits continues
above trajectory (6) reporting 17, a decline of one breach from May; the majority of breaches (14) being on an MSK pathway. The Trust is working towards
delivery of a remedial action plan, specifically focusing on the challenged sub-specialties within MSK and Plastic Surgery.
Cancelled Operations - In month, there were no urgent operations cancelled for a subsequent time and two breaches of the 28 day re-booking target. Root
cause analyses have been completed for all patients breaching the standard.
Diagnostic Waiting Times - The Trust has not achieved the national target for diagnostic waiting times with a performance of 6.84% in June and reflects a
deterioration from May’s position of 5.48%. The Trust has also failed to achieve the recovery trajectory of 6.00%. The Trust continues to monitor Endoscopy
pathways through Remedial Action Plans and outsourcing plans within Urodynamics are in place to commence clearance in July 2019.
Cancer
Cancer performance deteriorated in May, achieving two of the seven standards. Of the five standards not achieved, the Trust’s Two Week Wait has reported
another fall to 83.4% and the Breast symptomatic Two Week Wait reported 88.8% in May against the National standard of 93%. The majority of breaches relate
to Skin (104), Colorectal (107) and Breast (41). Patients receiving first treatment within 31 days of diagnosis has not achieved the standard and reports a
performance of 88.2% against 96% target. Patients waiting less than 31 days for subsequent surgery continues to underperform with a performance of 82.5%
against a target of 94% but has improved from April 2019. The current national submission indicates that the Trust failed the 62 day treatment standard, with a
performance of 78.9%. NHS Digital have acknowledged that there is an error in the 62 day reporting system and internal performance monitoring shows
performance should have been declared as 81.22%. The Trust continues to achieve the 31 day subsequent drug treatment standard with performance at 100%
and the target of patients treated within 62 days of screening at 91.8% against a target of 90%.
Areas of Concern
The system continues to monitor the effectiveness of all actions being undertaken, with daily and weekly reviews. The main risks identified to the delivery of the
Urgent Care Improvement Plan (UCIP) are as follows:
• UCIP Risk: Lack of community capacity and/or pathway delays fail to meet bed savings plans as per the bed model.
• UCIP Risk: Length of Stay reductions and bed occupancy targets in the bed model are not met leading to performance issues.
QUALITY PATIENT SAFETY AND EFFECTIVENESS
SRO: Medical Director and Interim Director of Nursing
Overview
Improvements
Never events –There were no Never Events in June 2019, with the last reported Never Event being 26th January 2019. The related CCG Contract Performance
Notice was closed on 16 July 2019.
Patient falls - The falls-per-1000 bed days level remains below the national average (6). Ongoing improvement actions agreed to support the national CQUIN.
MRSA cases - There have been no cases of MRSA bacteraemia in June 2019, the last being reported in February 2019.
Other infection types – The Trust is below trajectory for C-Difficile, MSSA and e-Coli and continues to sustain compliance above target with Hand Hygiene
requirements.
Missed Doses – The Trust is below target for the missed dose percentage and there strong governance arrangements are in place to address any individual
wards that miss the target for 2 consecutive months.
Learning From Deaths & Mortality Alerts – The Trust has delivered 91% of all required case reviews and continues to ensure that high priority cases are
delivered as required. There were no new notifications by a Reviewer of Overall care as Poor or Very Poor (score 1-2) within the latest review period.
Areas of Concern
Incidence of pressure injuries - For the current financial year there has been a significant increase in the number of reported Grade 2 injuries. Advice has also
been sought from the Tissue Viability team at NHSI to inform our programme of work. The Board has commissioned a presentation for the July meeting to
provide an understanding of the current position and assurance about the improvement actions being taken.
QUALITY EXPERIENCE
SRO: Interim Director of Nursing
Overview
Improvements
Complaint and Concerns: The number of complaints received in month has reduced further in June from 56 (May) to 52. Whilst there has been an increase in
the number of concerns addressed through PALS it is too soon to attribute this to the impact of this service. The Divisional Recovery Plans continue to deliver
improvement in the reduction of overdue complaints and the focus on preventing other complaints becoming over due.
Friends and Family Test: Maternity (Birth) sustained a high percentage of patients who would recommend the service to friends and family - 97%. The effective
communication by staff appears to have influenced the positive experience of the Mothers. It was agreed at the Patient Experience Group that we will increase
the number of patients asked the FFT question in Day Case to give us a broader understanding of the experience of patients in this area.
Areas of concern
Complaints and Concerns and Enquiries: It is crucial that the timely response to concerns and complaints is sustained by both the central and divisional
teams. The weekly recovery review meetings with the Head of Patient Experience focus on responsiveness to all complaints preventing overdue responses. The
Policy and Standing Operational Procedure for the management of complaints and concerns agreed at the Patient Experience Group (02.07.2019) gives clarity of
roles and responsibilities and process. Recruitment is in progress in the corporate and divisional teams to clinical governance and patient experience posts
which will help in this process.
Friends and Family Test. This month we had more feedback than average from patients who had come to hospital for an operation and have not had a positive
experience, it is too soon to see if this is a trend, but it will be monitored.
WELL LED
SRO: Director of People and Transformation and Medical Director
Overview Corporate Objective 4: Build effective teams empowered to lead
Improving the sustainability and wellbeing of our workforce
The improved position on sickness absence continues, with absence currently at 4.3% compared to 4.4% in 2018/19.
The activity taking place to reduce sickness absence and improve wellbeing, including the Wellbeing programme, is continuing and expanding. The positive
impact on Stress / Anxiety / Depression and Musculoskeletal absence continues with 1052 less fte days lost to absence for these reasons in the last 12 months
(Jun-18 – May-19) than the 12 months previously.
Improving the leadership capability and capacity of our workforce
The OneNBT Leadership programme has now met 92% (from 87% last month) of its 2019/20 target of staff signing up to the programme. Mandatory and
Statutory training compliance is at 90%. Compliance with appraisal completion is below the target for this month of 12% vs a target of 19.2% (month 3). People
Partners within divisions are reviewing the position and encouraging managers to increase completion.
Continue to reduce reliance on agency and temporary staffing
Agency use and expenditure increased in June predominantly in registered nursing (+20 wte), additional professional, scientific and technical (+7.8 wte) and
consultant (+1.9 wte) staff groups. The Trust Management Team have signed off a system approach to reducing tier 4/non-framework spend, and; the Trust
bank and agency task and finish group is moving forward with its action plan to improve the experience of our bank staff which in turn is anticipated to increase
bank participation and reduce reliance on agency staff.
Vacancies
The Trust vacancy factor increased to 10.8% in June 2019 from 101% in May 2019, the increase from May 19 predominantly resulted increases in funded
establishment across genetics with the greatest increase in vacancies being seen across qualified and unqualified scientific and technical staff as a result.
Vacancies across registered nursing and midwifery remains higher than the year end position in 2018/19. This is due to increases in establishment resulting
from the 2019/20 business planning round and an overall net loss of staff in quarter one of 2019/20, band 5 nursing also follows this trend. Despite this the
position for registered nursing and midwifery (and band 5 nursing) has seen a lower number of leavers and a higher number of starters in quarter one 2019/20
compared with quarter one in 2018/19.
Turnover
The Trust turnover saw a small increase from 15.2% in May to 15.5% in June. The increase is due to a higher number of voluntary leavers in June 19 (+20 wte)
than in June 18 causing the increase when comparing the rolling 12 month position. However the turnover remains over 1% lower than the start of the previous
financial year (16.7% in April 2018).
Stability
The stability factor increased in June compared with May 85.5% and 85.3% respectively. The rolling 12 month position for leavers with
FINANCE
SRO: Director of Finance
Overview
The Trust has planned a deficit of £4.9m for the year. This is in line with the control total agreed with NHS Improvement of £5.4m after excluding a planned profit
on sale of £0.5m which is no longer allowed to contribute to delivery of the control total under the new business rules for 2019/20.
At the end of June, the Trust reported a deficit of £3.4m which is £0.1m favourable to the planned deficit including Provider Sustainability Fund and Financial
Recovery Fund.
The Trust has borrowed a net £2.6m year to date to the end of June which brings the total Department of Health borrowing to £180.9m.
The Trust has a savings target of £25m for the year, of which £1m was achieved at the end of June against a plan of £4.2m.
The Trust is rated 3 by NHS Improvement (NHSI).
RESPONSIVENESS
Board Sponsor: Chief Operating Officer
Evelyn Barker
Urgent Care
The Trust did not achieve the ED 4 hour wait
trajectory of 89.23% in June 2019, with a
performance of 72.53%. The position has
deteriorated from May and also reflects a
deterioration when compared with June
2018.
A period of lower attendances mid-month
delivered an improved period of
performance, but this was not able to be
sustained, particularly in the latter part of the
month where significant increases in
attendances were experienced.
In June there was a small reduction in the
total number of attendances compared to
May 2019 at 8041. With an average of 268
attendances per day and four days
exceeding 300. At 8041, there were 294
(4%) more ED attendances in June 2019
when compared with June 2018.
ED performance for the NBT Footprint stands
at 80.69% and the total STP performance
was 83.59% for June.
4 hour wait times performance fluctuated
throughout the month, varying between
59.64% and 93.09%. Surges in attendances
led to operational challenges. ED staff
vacancies have reduced the Trust’s ability to
deal with surges in attendances, driving the
days of sub 60% performance.
4 Hour Performance
In June the majority of breaches (75%) were
attributable to ‘waiting ED assessment’. ED
assessment breaches have been driven by surges
of walk-in attendances and ambulances and staffing
gaps in Tier 1 and Tier 2 roles, especially at
weekends.
The Trust reported one 12 hour trolley breach on 25
June 2019 during a period of Internal Critical
Incident, which was declared following 3
consecutive days of high attendances and
admissions. Internal actions to drive the 4 hour
recovery are overseen by the Urgent Care Steering
Group. Key work streams include: increasing the
proportion of same day emergency care across all
divisions; criteria led discharge supported by
‘Perform’; implementation of primary care streaming
in ED; length of stay reduction plans; and
operational surge protocols.
Ambulance arrivals in June were 2750, this
represents a 4.9% increase on the same period last
year. Of patients arriving by ambulance, 93.70%
had their care handed over to the ED department
within 15 minutes and 98.90% were handed over
within 30 minutes. There were four 60-minute
handover breaches in month.
The overall bed occupancy position again improved
to 95.21% in June from 96.21% in May. On
average across the month emergency admissions
to the main bed base marginally reduced in June
compared to May. However, this is an increase of
21 emergency admissions per day when compared
to the same period last year.
DToCs and North Bristol Operational
Standards
The DToC remained steady during June as
a whole but there was an improvement in
delays in Bristol. This was linked to the
additional Social Work capacity provided
by peripatetic social workers undertaking
assessment. However, there remained a
significant cohort of Bristol delay linked to
Home First and delays in accessing
Reablement.
For South Glos., the reported delays
increased for P2 as there was an increase
in stroke referrals and the capacity could
not be extended to manage demand. In
addition, the numbers waiting for
placement increased in the month.
Stranded patient levels for over 21 days
did improve in June, however levels for
over 50 days increased. The delays in
moving complex strokes and neuro through
to either P2 or NHSE specialist
commissioned beds within BIRU has led to
extended delays in both pathways. The
latter has been escalated to CCG leads.
The NHSI Long Length of Stay process
has been initiated to include reviews with
partners and ward teams to further inform
the Trust and system partners of the level
of demand for internal and external action
to promote discharge. The first full month
of results will be reported in July.
Referral to Treatment (RTT)
The Trust has not achieved the RTT
trajectory in month with performance of
85.03% against trajectory of 87.60%.
The RTT wait list size has not been achieved
for June, reporting 28,590 against a trajectory
of 28,148, but did decrease compared to May
following a targeted piece of data quality
work. The remaining waiting list increase is
primarily for patients waiting less than 18
weeks. This is driven by a mixture of reduced
activity in some specialties (Urology, Breast
Surgery and Gynaecology) and an increased
demand in others (Plastic Surgery and
Gastroenterology). The RTT Incomplete
performance gain, that would be expected
from an increase in patients waiting less than
18 weeks, has been offset by a deterioration
in performance for Neurology.
The Trust has reported a total of 17 patients
waiting more than 52 weeks from referral to
treatment in June 2019. These patients were
within the following specialties:
14 Trauma and Orthopaedics;
1 Plastic Surgery;
1 Urology; and
1 Neurology.
12 of the 14 Orthopaedic long waiters and all
other speciality breaches are as a result of
capacity issues, with the remaining two of the
14 Orthopaedic breaches attributable to
pathway delays. Root cause analyses have
been completed for all patients, with future
dates for patients’ operations being agreed at
the earliest opportunity and in line with the
patient’s choice.
Cancellations
The same day non-clinical cancellation rate in June 2019 was 0.79%,
which attained the 0.8% national target for the first time in 12 months.
In month, there was no urgent operation cancelled for a subsequent
time.
There were two operations that could not be rebooked within 28 days
of cancellation in June 2019. Both Nephrology patients were cancelled
on the day due to an urgent transplant patient. Unfortunately due to
other Urgent and Transplant patients taking priority, these patients
were unable to be rebooked within 28 days; these patients have now
been treated.
Root cause analyses have been completed to ensure that there is no
patient harm.
Diagnostic Waiting Times
The Trust did not achieve the 1.00% target for diagnostic performance in June 2019 with actual
performance at 6.84%. This is a decline in performance from the May 2019 position, and did not
achieve the trajectory of 6.00% for June 2019. This is the first time this year that the trajectory has
not been delivered.
Six test types have reported in month underperformance: Urodynamics; Computed Tomography (CT);
Flexi-Sigmoidoscopy; Colonoscopy; Gastroscopy; and Cystoscopy.
Urodynamics has reported an improved position in June at 37.17% from 44.33% in May. There were
100 patients waiting more than 6 weeks in month. Outsourcing of activity has been agreed with six
lists arranged with an alternative provider. The first three of these lists are being delivered in July with
a further three lists planned for August. This will allow rapid backlog clearance. Any residual backlog
following delivery of these lists will be reviewed for September and outsourced if required. The
recurrent capacity within the service should then be back in balance with demand.
Flexi-Sigmoidoscopy test position reports another decline in performance at 36.75% in June from
33.54% in May with 122 patients breaching the 6 week waiting time standard against a total wait list
size of 332. The Colonoscopy position deteriorated further in June with performance at 34.04% from
26.13%, with 176 patients waiting over six weeks against a total wait list of 517. Gastroscopy have
reported a declined position of 26.35% in June from 21.52% in May, with 146 patients waiting over six
weeks.
Contracts for insourcing of Endoscopy activity have been agreed and the Contract for outsourcing has
been progressed. The work with Commissioners on demand management across the system has
commenced this month. The recovery trajectory for these tests is being reset to take account of the
impact of this increased capacity.
Cystoscopy test position has again breached the national target in June with an almost static
performance of 4.79% from 4.82% in May. As at June, there were still 16 patients waiting more than
six weeks for a Cystoscopy against a total wait list of 334.
CT has again breached the national target in June with performance of 7.22% from 3.44% in May.
There are 155 patients waiting more than six weeks against a total wait list of 2146. Despite running
additional weekend lists the Trust is experiencing higher levels of breaches in CT as a result of
staffing issues. The Trust will need to reduce outpatient CT capacity in the short term to ensure
adequate cover for the 24/7 Emergency CT rota. This will continue to have an adverse impact on the
DM01 position. The Imaging Team is seeking to mitigate the current staffing shortages through the
appointment of locums.
All other test types have reported patient diagnostic waiting times within the six week standard.
Cancer
The nationally reported cancer position for May
2019 shows the Trust achieved two of the seven
cancer waiting times standards. The Trust failed
the TWW standard with performance of 83.4%
which is a worsened position from April. The
Trust saw 2049 TWW referrals in May and there
were 340 breaches; the majority were in Skin
(breaches-104, referrals-566), Colorectal
(breaches–107, referrals-362) and
Breast(breaches–41, referrals-450).
Of the 340 breaches, 196 patients declined or
cancelled the appointments offered within target.
If these were attended then performance would
have been 92.73%. The Trust is undertaking a
joint investigation and action plan with the CCG
to address ongoing performance issues against
this standard.
Capacity issues within Endoscopy and Radiology
caused significant performance issues within
straight to test pathways for Colorectal, Upper GI
and Lung. The Trust is forecasting ongoing
issues with capacity for Skin through out the
summer and the speciality is currently trying to
address these issues.
The Trust failed the 31 day first treatment
standard with a performance of 88.2% against
the 96% target. There were 28 breaches in total;
22 in Urology, two in Breast, two in Colorectal,
one in Sarcoma and one in Skin. Urology
breaches were due to delays to robotic surgery,
due to a continued increase of patients requiring
these procedures as first and subsequent
treatments which will be resolved when the
second robot is fully operational and the backlog
cleared. The Skin breach was a medically
appropriate delay and all other breaches were
due to capacity for surgery.
The national submission for the 62 day standard in May indicates the Trust failed the 62 day
treatment standard with a performance of 78.91%. There has been acknowledgement from NHS
Digital that the new national reporting system implemented in April 2019 is not calculating
performance correctly and the Trusts internal monitoring shows that 62 day performance was
actually 81.22%. This would still be a fail against the 85% standard but a significant difference to
the nationally reported position. The Trust has escalated this issue to the CCG and NHSE
through the Access and Performance Group.
In May, 31 patients breached the 62-day standard, 21 of which started their pathway at NBT. Of
these 21 patients, 20 had their first appointment at NBT after day seven.
Urology breaches accounted for 71% of total Trust breaches for May. Capacity issues in
radiology, biopsy, joint oncology clinics and robotic theatres continue to limit the ability to meet
the 62 day standard for Urology. Radiology capacity for prostate patients was increased in June
which should enable all patients to receive their MRI on the day of first appointment. Reporting of
these scans within adequate timeframes will remain an issue
The continued delays for Oncology outpatient appointments and robotic surgery capacity will
continue to impact performance for the foreseeable future. The Trust continues to address delays
for Oncology capacity with University Hospitals Bristol and a draft SLA for Oncology provision
requirements has been submitted to UHB.
The Urology RAP and recovery trajectory is now predicting recovery of the standard in
December/January. This is due to the ongoing recruitment of additional pelvic oncology surgeons
and the existing backlog of patients requiring robotic surgery that will require clearing.
The continued increase of late tertiary transfer patients from elsewhere in the region and the
clearing of the associated backlog has continued to impact on Urology performance. Of the 22
Urology breaches, 10 were transferred in from other providers for treatment, nine of which were
beyond the agreed national transfer date, accounting for 4.5 additional breaches. Nine of these
patients had exceeded the 62 day pathway prior to being referred to the Trust.
Other breaches recorded in May were; three in Breast (all complex pathways), one in Colorectal
(patient delayed treatment), two in Gynaecology (one administrative delay at UHB and one
complex pathway), one in Haematology (complex pathway), one in Lung (delays to diagnostics)
and one in Upper GI (complex pathway).
As part of performance improvements the Trust has been monitoring it’s internal performance
against the 62 day standard. The Trust treated 87.6% of all patients who were referred to and
treated at NBT within the national standard. This shows the Trust passed the standard for internal
patients including Urology.
The Trust failed the 31 day subsequent
treatment target in May 2019 for patients
requiring surgery with a performance of
82.5% against the 94% standard. This is an
improved position from April and has
achieved the trajectory for May.
The continued failure against this standard
has resulted in a contract performance
notice being issued by the CCG. The Trust
has submitted an action plan to recover this
position, with significant improvements now
forecasted from December 2019.
There were 17 breaches in total; three of
which were in Skin and 14 in Urology.
Performance against this standard will
improve once the second robot and
associated staffing is fully operational and
the significant backlog is cleared. The new
theatre schedule was implemented the
beginning of April the Skin performance
against this standard has improved as
forecasted.
The Trust achieved the 31 day subsequent
standard for patients receiving anti cancer
drugs with a performance of 100%.
The Trust achieved the 62 day screening
target with a performance of 91.8% against
the target of 90%.
There were two breaches in Breast. Two
were due to patient choice delay within the
pathways and one due to a complex
pathway requiring multiple diagnostics.
There was one breach in Colorectal due to
patient delaying their pathway.
ED 4 Hour Performance
NBT ED performance in June 2019 is
72.53% compared to a national Type 1
position of 78.80%. The position reflects an
decline from May and a deterioration when
compared to the same period last year.
RTT Incomplete
The Trust reported an May 2019 position of
85.14%. This position reflects an decline
on last year but falls under the national
position of 86.86%.
Cancer – 62 Day Standard
NBT has reported 78.95% performance for
May and continues to outperform the
national position of 77.45%.
DM01
NBT, in May 2019, failed to achieve the
National standard of 1% with a
performance position of 5.48%, against the
national position of 4.08%.
ED 4 Hour Performance
In June, NBT moved from a position of
#75 to #93 out of 119 reporting Type 1
Trusts. This decline has moved the
Trust back into the 4th quartile. The
Trusts ranking among the 10 Trauma
centres declined from 3rd to 6th in June
2019.
RTT Incomplete
RTT performance in May 2019 reports a
deteriorated NBT position of #126 out
of 177 reported positions. The Trust
now ranks 5th out of 11 other adult major
trauma centres.
Cancer – 62 Day Standard
At position #66 of 138 reported
positions, NBT reports performance of
78.95%. This represents a deterioration
in positioning from April 2019 and ranks
3rd out of 11 major trauma centres.
DM01
NBT reports a deteriorated position of
#142 out of 204 reported diagnostic
positions, with a performance of 5.48%
in May. This position ranks 8th out of 11
adult major trauma centres.
Safety and Effectiveness
Board Sponsors: Medical Director and Interim Director of
Nursing
Chris Burton and Helen Blanchard
Recruitment • Recruitment of midwives to fill the new and vacant
posts has been underway since October 2018. The
total resource required at that point was 23.8 WTE
(16.26 WTE new posts and 7.54 WTE vacancies).
The forthcoming pipeline is comprised of 19
midwives with start dates over the next three months:
two between July and August, followed by 17
midwives in September 2019.
• Interviews for the substantive post of Bereavement
Midwife are taking place on 22nd July 2019. This vital
post will provide support to women and their families
following the introduction of new national
bereavement care pathways.
• Interviews for the QI Lead Midwife will take place on
02 August 2019. This is a Band 7 substantive post
and will lead on quality improvement programme
agenda.
• We are currently recruiting to the post of Lead
Sonographer role which is out to national advert.
• We will also be advertising shortly for a Band 7 IT
Maternity Lead.
Midwifery Led Services • A temporary closure of Cossham Birth Centre has
been in place since October 2018 due to a shortage
of midwives and increasing inductions of labour at
Southmead Hospital. The closure will be reviewed
by Trust Board on 25 October.
• A review of Midwifery Led Services at NBT from a
quality, safety and efficiency perspective is ongoing
and has included engagement sessions with staff A
progress update will be presented to the Trust Board
in July 2019.
Wave 3 Maternity & Neonatal Health Safety
Collaborative (MNHSC) • This is going well with excellent multi-disciplinary
engagement and attendance at the daily huddle.
• NBT focus is Post Partum Haemorrhage.
• A programme is in place to communicate and update
all staff via a ‘tea trolley’ on CDS and also the PPH
Station at the intrapartum study day. ‘My Pregnancy @ NBT’ smartphone app launched on 04 May 2018 to replace patient information leaflets and give women and families access to evidence based care ‘on-the-go’ wherever and whenever they choose.
Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19
511 534 543 515 535 497 491 478 458 448 439 490 454
01:30 01:30 01:33 01:33 01:33 01:30 01:31 01:30 01:30 01:28 01:27 01:30 01:28
56.0% 56.1% 56.4% 60.1% 51.8% 53.1% 51.1% 56.0% 51.1% 55.7% 53.7% 56.3% 56.1%
29.1% 28.5% 31.2% 27.3% 34.1% 32.1% 34.4% 32.1% 37.9% 32.0% 35.0% 30.8% 30.4%
18.0% 17.3% 17.1% 14.6% 18.7% 19.2% 19.1% 18.0% 23.0% 17.7% 22.4% 19.30% 21.2%
34.1% 35.0% 33.1% 35.7% 34.7% 34.9% 33.4% 34.0% 37.7% 38.3% 41.5% 36.10% 43.0%
17.8% 19.9% 19.3% 18.8% 13.4% 14.3% 7.9% 14.9% 12.0% 14.5% 15.3% 17.90% 14.1%
5.7% 6.1% 6.4% 2.8% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0% 0.0%
11.5% 12.9% 12.1% 14.3% 12.1% 12.9% 6.7% 12.6% 10.7% 13.4% 12.8% 16.6% 12.8%
0.6% 0.9% 0.4% 1.4% 3.0% 1.2% 1.2% 2.3% 1.3% 1.1% 2.5% 1.2% 1.3%
81.0% 79.2% 80.4% 79.8% 83.7% 84.5% 89.6% 83.7% 86.7% 83.3% 84.0% 80.3% 83.6%
96.9% 97.0% 95.7% 95.4% 96.4% 95.4% 95.9% 97.4% 97.7% 96.0% 98.3% 98.3% 100.0%
Actual 4 0 1 1 2 1 2 2 3 5 2 2 2
Rate 0.80% 0.00% 0.20% 0.20% 0.40% 0.20% 0.40% 0.41% 0.60% 1.10% 0.2% 0.0% 0.0%
Birth
Total Births
Home
Induction of labour rate
Normal birth rate
Caesarean birth rate
Midwife to birth ratio
Total births in midwife led environment
Emergency caesarean birth rate
CDS
One to one care in labour
Birth location
Stillbirth
Cossham BC
Mendip BC
CQC Inspection • The anticipated CQC inspection of Women & Children’s Health commenced on 25 June 2019.
• Inspectors visited clinical areas and spoke with staff. Information requests were submitted and meetings with
senior Divisional staff took place.
• An out of hours visit to the unit took place on 11 July 2019.
• Feedback is awaited.
Quality & Patient Safety - Additional Safety Measures Board Sponsor: Director of Nursing Serious Incidents (SI)
Three serious incidents were reported in
June 2019:
• 1 x Patient Falls*
• 1 x Safeguarding
• 1 x Maternity & Obstetrics
The Board is asked to note that from April
1st onwards NBT will declare on STEIS all
“Serious Falls” as Serious Incidents.
Therefore, “non-STEIS falls” will no longer
be reflected as a separate category. This
means that Falls represents our most
frequently occurring Serious Incident.
Never Events:
There were no Never Events in June 2019,
with the last reported Never Event being 26
January 2019.
SI & Incident Reporting Rates
Incident reporting has increased slightly in
June to 45.6 per 1000 bed days. Whereas
NBT’s rate of reporting patient safety
incidents remains within national
parameters, it is noted that we are in the
lower quartile of similar NHS Trusts.
The Patient Safety Incident Improvement
Project is focusing on improving our rates of
reporting to facilitate learning.
Divisions:
SI Rate by 1000 Bed Days
CCS – 0.58
WCH – 0.27
ASCR – 0.19
Med – 0.17
NMSK – 0.11
Quality & Patient Safety - Additional Safety Measures Board Sponsor: Director of Nursing
Data Reporting basis
The data is based on the date a serious incident is
reported to STEIS. Serious incidents are open to
being downgraded if the resulting investigation
concludes the incident did not directly harm the
patient i.e. Trolley breaches. This may mean changes
are seen when compared to data contained within
prior Months’ reports
Central Alerting System (CAS)
4 new alerts reported, with none breaching their alert
target dates.
From June 2019, the Patient Safety and Clinical Risk
Committee will receive a monthly status report on
CAS alerts. This report will provide information on
new alerts with updates for open alerts.
Incident Reporting Deadlines for
Serious Incident Investigation
submission
No serious incidents breached their
June 2019 reporting deadline to
commissioners. There have been no
breaches since July 2018.
Top SI Types in Rolling 12 Months
Patient Falls remain the most
prevalent of reported SIs. These are
monitored through the Trust Falls
Group, with an update being provided
to the next Patient Safety and Clinical
Risk Committee (June 2019).
This is followed by
Treatment or Procedure
Maternity & Obstetrics.
“Other” Category:
1 Appointment
1 Medication
1 Fluid Management
1 Safeguarding
Falls
In June 2019, 152 falls were reported of which one resulted in
severe harm, five were categorised as moderate, 43 low and the
remaining 103 as no-harm.
The majority of reported falls occurred within Medicine Division (81),
with the others occurring in NMSK (53), ASCR (16), in CCS (3) and
Women’s and Children (1).
The falls-per-1000 bed days level continues to sit below the
considered national average (6.1).
The mandated risk assessment fields are now in place on
LORENZO and the data collection process is fully underway for the
Falls national CQUIN for 2019/20. This will enable the achievement
of the CQUIN standards.
Currently 30 of the 100 patient submissions have been collected for
the first quarter. It is anticipated that all 100 will be completed before
the submission deadline. The main challenge sits with the
completion of lying to standing blood pressure assessments.
Additional teaching has been is continuing for the Falls Link Nurses
for dissemination across the wards.
The initial submissions show that compliance with the other 2
criteria, recording of sedation medication and mobility assessments,
are good.
Pressure Injuries (PIs)
The Trust ambition for 2019/20 is a
• 30% reduction of Grade 2 pressure
injuries.
• 30% reduction of device related
pressure injuries
• Zero for both Grade 4 and Grade 3
pressure injuries.
No grade 3 or 4 pressure injuries were
reported in June 2019.
There were 31 reported Grade 2
injuries which occurred to 27 patients.
The break down of injury is as follows:
61% Sacrum/ buttock, 13% Heels, 6%
Face and 10% Medical device related.
The organisational response, to the
increase in the incidence of pressure
injuries, continues with the Heads of
Nursing and matrons across inpatient
areas undertaking key elements of
quality improvement:
• Actions to prevent PIs,
• education and training,
• monitoring and audit.
Advice has also been sought from the
Tissue Viability team at NHSI to inform
our programme of work.
The Board has commissioned a
presentation for the July meeting to
provide an understanding of the current
position and assurance about the
improvement actions being taken.
VTE Risk Assessment
The Board expects a VTE risk assessment to be carried out for all appropriate in-
patients. Where certain procedures are considered to be of low risk, the assessments
may be agreed as a patient cohort. Cohorts are signed off by the Medical Director. The
Trust continues to meet the national standard of 95% of patients have a documented
risk assessment in their records at the point of coding the discharge.
WHO Checklist Compliance
The Board expects that there will be a WHO surgical safety checklist documented prior
to each operation in theatres.
Measured compliance with the WHO checklist was 97.0% in June 2019. WHO
checklist compliance is monitored by the Theatre Board with any areas failing to record
compliance with the requirement being addressed by the relevant leadership team.
Fractured Neck of Femur in Patients
aged 60 years and over
Patients admitted to an acute
orthopaedic ward within four hours.
Hip Fracture data is reported one month in
arrears with current month included for
reference.
In May 2019 the percentage of patients
who were admitted to Hip Fracture unit
within 4 hours was 59.3% against an
England average of 41.4%.
Patients medically fit to have surgery
have surgery within 36 hours.
In May 77.8% of patients received surgery
within 36 hours compared to the England
average of 71.8%. North Bristol NHS
Trust is investing in additional trauma co-
ordinators with a view to further improving
this.
Patients assessed by an
Orthogeriatrician within 72 hours.
In May 2019, 96.3% of patients were seen
by an Orthogeriatrician within 72 hours.
Stroke
Stroke data is reported one month in
arrears with current month included
for reference.
67 patients were admitted to
Southmead hospital with stroke in
May 2019.
71.4% of stroke patients requiring
thrombolysis received this within 1
hour which is sustained performance
better than the England average but
continues to be a focus in the stroke
team.
Admission to a stroke unit within 4
hours of presentation remains a
challenge with performance at 58.2%
in May 2019. The main problem is
the overall bed occupancy and the
Stroke service is working with the
Operations team to ensure the
availability of stroke beds at all times.
The number of patients scanned
within 1 hour remains higher than the
England National average at 70%
In May 2019.
Medicines Management
Severity of Medication Error
During June 2019, the number of “No
harm” medication errors represented
c.83% of all medication errors
demonstrating a strong reporting
culture.
The Medicines Governance Group is
investigating a small rise in ‘low harm’
incidents to determine what actions are
required.
High Risk Drugs
High Risk Drugs formed c.27% of all
medication incidents reported during
June 2019. All incidents relating to high
risk drugs are closely monitored by the
Medicines Governance team.
Missed Doses
The clinical pharmacy team continues
to closely monitor the KPI’s associated
with all missed doses. Any ward(s) that
breach the missed dose target of
MRSA
There have been no cases of MRSA
bacteraemia in June 2019.
In June an increased incidence of MRSA
colonisation was reported within the
Neonatal Intensive Care Unit. An
Incident Meeting was held, which
established evidence of cross infection.
There have been no new cases reported
since 23 June 2019, with all colonised
babies have been discharged.
C. Difficile
NHS Improvement have changed the
measurement methodology for C. diff
resulting in a new 19/20 target total of 57
cases.
In June there were six cases reported
against the trajectory. Five cases were
hospital onset and one case was
community onset.
Clinical reviews will be carried out using a
multi-disciplinary approach to determine
whether there are links to any lapses in
care.
MSSA
The Trust target for 2019/20 is fewer than
26 cases.
There was one reported case of MSSA
bacteraemia in June within the Medical
division. A Trust quality improvement
initiative continues, aiming to reduce
incidence of bacteraemia associated with
indwelling devices.
E. Coli.
The Trust target for 2019/20 is 51
bacteraemias representing a 10%
reduction on the previous year.
There were five cases of E. Coli
bacteraemia reported in June.
The focus for improvement is on the
management of urinary catheters.
Hand Hygiene
Hand Hygiene compliance has been
maintained.
Surgical Site Infection Reporting
NBT undertakes mandatory SSI
reporting for infection following hip
and knee replacements, which is
coordinated by the NMSK Division.
There is monitoring though the
Control of Infection Committee.
During 2018/19 orthopaedic SSIs
have been higher than the national
bench mark. A quality improvement
programme, led by a Consultant
orthopaedic surgeon, is in place to
review all aspects of the patients
pathway from referral to discharge.
This divisional collaboration involves
stakeholders from NMSK, ASCR and
Infection Prevention and Control.
Mortality Review
Completion
Overall Mortality
The Trust’s SHMI Mortality Ratio for the most
recently calculated period is within the expected
range. (Due to changes in national reporting,
there has been no change to the SHMI reported
from last month).
Mortality Review Completion
The current data captures the completed reviews
up to 31 March 2019. In this time period, 90.93%
of all deaths have a completed review. 97.3% of
“High Priority” cases have completed Mortality
Case Reviews (MCR) including 15 deceased
patients with Learning Disability and 15 patients
with Serious Mental Illness.
Mortality Review Outcomes
The number of cases reviewed by MCR with an
Overall Care score of adequate, good or
excellent remains 97% (score 3-5). There were
no new notifications by a Reviewer of Overall
care as Poor or Very Poor (score 1-2) in March
2019.
Mortality Review
Outcomes
Quality Experience
Board Sponsor: Interim Director of Nursing
Helen Blanchard
Complaints and Concerns
In June 2019 the Trust received 52 formal
complaints and 93 PALS concerns.
The 52 formal complaints can be broken down by
division:
ACSR: 17 CCS: 4
Medicine: 12 NMSK: 13
Ops: 1 WACH: 3
Clin. Gov: 1 IM&T: 1
This shows a continued slow decrease in the
number of formal complaints. It is too early to
attribute this to the impact of PALS. The Clinical
Governance complaints related to a safeguarding
issue whilst the IM&T complaint related to access to
medical records.
Final Response Rate Compliance
Following the successful roll out of corporate and
divisional recovery plans throughout June, the
compliance with providing timely responses at end
of month of June had risen to 71%.
N.B. Trust-wide chart showing 2019-20, starting April 2019 and will show rolling data going forward. Feb-19 and Mar-19 data has
been removed for complaints, concerns and overdue complaints owing to data quality issues.
Division Total closed in
June
Total overdue at end of June
Medicine 16 4 NMSK 12 2
ACSR 16 11
CCS 3 1
WACH 1 1
Clin Gov 1 1 Total 49 20
June 25 60% compliance
July 20 70% compliance
August 10 80% compliance
September 5 90% compliance
October 0 – maintain target 100% compliance
November 0 – maintain target 100% compliance
Overdue complaints
The total number of overdue complaints at the end
of June sat at 20. At the week of 10th July this had
reduced further to 11 overdue cases, reflecting the
success of the recovery plans.
Compliments
A more systematic approach will be developed to capture compliments and will be developed as
part of the ongoing improvement programme. This will follow the current priorities of addressing
the complaints backlog and establishing a permanent PALS service.
Patient Advice and Liaison Service (PALS)
Following a pilot of the PALS service between Feb-Apr 2019, a new PALS concern chart is now
included to give an overview of service provision going forward.
93 PALS concerns were received in June 2019 ( 82 in May). Of the 93 PALS concerns received in
June 2019, 74 (80%) can be classified as more simple concerns and 19 warranted more in depth
investigation from within the division and were classified as complex concerns. The issues arising
through concerns are recorded and there will be reporting in a similar way to concerns once
capacity has increased in the team through the appointment of a PALS manager.
A revised policy ‘CG20 – Policy & Procedure for Management of Complaints and Concerns’
together with a new standard operating procedure ‘Management of Complaints and Concerns’
was approved at the Patient Experience Group (PEG) meeting of 02 July. This will be rolled out
throughout the Trust together with training sessions on investigation of complaints, writing formal
complaint responses and the local resolution of concerns. The SOP includes process flowcharts
on the new triage process and categorisation and compliance standards for formal complaints &
PALS concerns. A Datix training programme will also be rolled out alongside the policy.
Friends and Family Test
Owing to technical issues, NHS England have not published
maternity FFT data for November 2017.
N.B. NHS England FFT Official stats publish data one month behind current data presented in this IPR.
May 2018, South West region has been split to SW (North) and SW (South). NBT is now plotting against SW (North).
ED 15% 20.56%
Inpatients 30% 17.40%
Outpatients 6% 11.74%
Maternity (Birth) 15% 21.05%
FFT Response
RateNBT ActualTarget
Following the resolution of the issue
identified that effected the Interactive Voice
Message (IVM) FFT which we use to
survey all patients over 60, which
continued until 09 May, we have now seen
response rates return to normal
parameters.
Following a period of decline, ED have
continued to improve their response rate.
Owing to technical issues, NHS England have not
published maternity FFT data for November 2017.
N.B. NHS England FFT Official stats publish data one month behind current data
presented in this IPR. May 2018, South West region has been split to SW (North)
and SW (South). NBT is now plotting against SW (North).
ED 90% 88.01%
Inpatients 95% 92.82%
Outpatients 95% 95.63%
Maternity (Birth) 95% 96.74%
FFT Recommend
RateTarget NBT Actual
There has been no significant change in the
percentage of patients saying they would
recommend the Inpatient wards. Outpatients
remain within normal levels and are achieving
the target. Maternity (Birth) have achieved a
fantastic result of almost 97% of patients
recommending their services.
After a period of decline ED continue to make
an improvement.
What are people saying about our
services?
Within inpatients, the majority of negative
feedback relates to people who have come in
to hospital for an operation. The feedback
ranges from inadequate environment for
recovery due to mixed sex bathrooms a long
walk from bed, lack of after care information
and cancellations. In response to this
continuing trend we will increase our provision
to survey more day case patients to fully
establish the issues arising.
Within ED the feedback remains to be around
waiting times and the lack of communication
around this.
Maternity received no negative feedback again
(Birth), the staff and their communication are
cited as the main reasons for the positive
experiences.
Friends and Family Test
“Please tell us the main reason for the answer you chose.”
ED – (1)
Everyone I met from the paramedics that
came and took me to hospital, through to the
nursing staff and lovely doctor who looked
after me were superb. It was a very busy
night with over 70 patients to be treated but I
was still very well cared for with
thoroughness, kindness and consideration. I
was kept informed of the progress of my tests
and what would happen next and never left
wondering what was happening.
9a – (1)
Due to my health issues, I've been in a
few hospitals. If this ward is anything
like your other wards then you're doing
something right. the consultant team,
nursing staff, cleaners and food are
excellent. I'll be writing a letter of
thanks when I get out, great ward
Gate 9a.
Elgar 1 (1)
All the staff who work on Elgar 1
are very kind and serving you
could not get better treatment
anywhere else. I thank you all for
what you have done for me.
Outpatients - Urology (5)
My appointment was at 9am. I was kept waiting for
nearly an hour and a half. No explanation was
offered. I was not advised I would be kept waiting.
Outpatients - Gastro (3) Reducing the waiting time!! I had to wait
90 minutes (1 HR 30) for my
appointment. The delays were known
early in the day, so why couldn't a
message be sent to advise of slips and
to arrive 30 minutes or 1 HR later than
expected? And why didn't the 2nd
scheduled doctor arrive that day?
Cotswold – Gynae (5)
Hospital ward was very cold
unfriendly was at hospital all
day waiting for op hungry
thirsty then to be told at 6pm
op cancelled! (after already
been given pain meds for
after op ) it feels like you are
just left with no
communication at all.
26a (1)
I was greeted by a nurse who informed me that
she would be with me up until the time I went to
theatre. The nurse explained any tests and
made me comfortable. All involved explained
their role and encouraged me to ask questions.
Post operative care was excellent and a nurse
called my family informing them I was now on
ward. Pain relief and monitoring was regular
and nursing staff were encouraging and
reassuring in their care.
ED (5)
Really long wait. Gave up and left after
being told that some people had been
waiting 8 hours. There was a cat in the
hospital which although I like cats, seems a
bit unhealthy and my partner is allergic.
Outpatients - Radiology (5)
The discussions with Dr about
my problems and results of MRI
were in an open waiting area
where everyone (members of the
public) could hear. Excruciatingly
embarrassing.
Research and Innovation Board Sponsor: Medical Director
In line with last year, and regional patterns NBT is
currently behind the linear target. However a
number of large recruiting studies are due to open
within the next 2 months which it is anticipated will
address the current shortfall.
The number of NIHR studies lead by non-medic
researchers has continued to show strong
performance.
Due to a generous charitable donation to the NBT
Research Fund, R&I will be opening a Trust-wide
open call for applications to fund research projects
up to £20k each. The call will open at the end of
July 2019.
NBT received it’s 2019/20 Research Capability
Funding (RCF) allocation from DoH and, at
£1.1m, this represents a 34% increase to last
years budget, resulting from NBT’s NIHR grant
success over the last year.
As a result we were able to open a call for
applications from NBT researchers to fund key
posts within their team to develop future NIHR
grant applications. From this call we have agreed
to fund 1.5wte Research Facilitator posts within
the Medicine Division and Respiratory and Stroke
research teams.
NBT currently holds 31 research grants (NIHR,
charity and other) to a total value of £18.2m, with
14 NBT-led grants in set-up (£4.94m).
NBT R&I hosted an Investors in People
assessment and have now progressed to a silver
award standard.
Facilities
Board Sponsor: Director of Facilities
Simon Wood
Operational Services Report on Cleaning
Performance against the 49 Elements of
PAS 5748 v.2014 (Specification for the
planning, application, measurement and
review of cleanliness in hospitals)
Cleaning scores for the 2nd month in
succession for all risk categories‘ have met
or exceeded their target.
The ED Task Team have been in place
since 03 June. We have received positive
feedback from our clinical colleagues
regarding the high standards of cleanliness
and responsiveness. We have started to see
a steady improvement in cleaning scores
within ED. A Task Team has been created to
work in AMU replicating the ED model, this
team went live as of 01 July.
The total number of whole time equivalents
within the Relief Team stands at 45 (2.5
vacant). The team is used to provide cover
for vacancies that arise out of leave or
sickness, reducing the reliance upon NBT
extra to backfill shifts.
Deep clean numbers per week were in line
with the previous month with an average of
247 carried out per week 96.63% of which
were above the key performance indicator
for 4 hour breaches. Work is currently
underway to identify the cause of such a
high number of deep cleans being
requested.
Well Led
Board Sponsors: Medical Director, Director of People and
Transformation
Chris Burton and Jacqui Marshall
Substantive
June expenditure is 187k under budget. The
Trust is £1.27m under budget year to date.
June worked wte is 178 wte under funded
establishment.
Temporary Staffing
NBT Extra
Work is being completed to increase the
attraction to bank for all staffing groups as we
enter the summer holiday period.
Standards have now been finalised for the
BNSSG wide compliance checks process, so
that consistency is achieved across the
region and processing efficiency is improved.
The current bank rates are under review as
part of the Bank rates Task and Finish Group
with further updates to follow in the forth
coming months
Agency
Agency expenditure has increased during
June due to high demands for registered
nurses.
The BNSSG Agency Project which is working
to reduce high cost agency usage has now
meet with all agencies suppliers to agree
setting a standardised charge rates which will
mirror rates introduced by the Welsh Trusts
back in 2017 which enabled the exclusion of
non framework high cost agencies in the
region.
Unregistered Nursing and Midwifery Recruitment
A band 2, 3 and 4 resourcing plan identifying the continuous talent attraction initiatives
scheduled between April 2019 – March 2020 is in place. This will be supported by an
improved reporting process for vacancies, retention and numbers of new starters for this staff
group to ensure consistent Trust wide visibility. In June the Trust had 17.6 external new
starters, the year to date position is 60.8 wte against a target of 43 wte.
Band 5 Nursing
The Band 5 nursing vacancy gap increased in June due to 294 wte across the five clinical
divisions. There were eight new starters in June which means year to date the Trust is 13.2
wte starters behind target.
However the continuing programme of events in the resourcing plan delivered 3 key
engagement events in June;
• RCNI Careers Day in Bristol, including a 2 seminars from the Clinical Simulation and
Stroke teams
• Nursing Times Careers event in London
• Facebook live webinar delivered by the Complex Care team to an audience of 150
viewers
June also saw 60 offers made for start dates between July and September which will bring
the trend back in line with annualised targets and the planned reduction in the Trust wide
vacancy factor. In additional bespoke recruitment plans were signed off for Renal and
Theatre.
Overseas Nurse and Midwife Recruitment
The International Nurse Recruitment project continues to deliver experienced permanently
employed Nurses from the Yeovil pipeline. One nurse started in June with 12 more to start in
July. Visa processing delays have created a lag in the anticipated timeframes with final
numbers anticipated to be 37 nurses from this pilot with Yeovil by the end of September
2019. The OSCE and pastoral care team are delivering their wrap around welcome and
support to the nurses as they arrive at the Trust and we are receiving positive feedback from
the Nurses on their experiences with the Trust to date. A review of the pilot will take place in
July 2019 as well as additional potential pipelines and recommendations will be made to the
Nursing and Midwifery Nursing Group on the Trusts future approach to international
recruitment as a whole.
Stability and Turnover
Overall the retention indicators all show a
positive movement over time, however the
rolling 12 month voluntary turnover positon
did increase in June 2019 along with the
leavers for work life balance reasons. There
were more voluntary leavers in June 2019
than June 2018 that cause the increase form
last month.
As with overall voluntary leavers the rolling
12 month position for work life balance
leavers deteriorated slightly as the number of
leavers for this reason was higher in June
2019 than in June 2018. Increases in
registered and unregistered nursing and
midwifery contributed to this movement.
Actions
• New Leavers Questionnaire and process
to be rolled out from August, which should
give more real-time data on reasons for
leaving;
• We are developing a programme of P&T
support for new, international nurse
recruits to ensure they feel well-supported
during their first months in post;
• Work continuing around re-promoting
flexible working via a new brochure-type
resource for staff and managers which
details all the options, links and guidance
around flexible working.
Sickness
Sickness absence for Stress, Anxiety and
Depression (SAD), and Musculoskeletal (MSK)
reasons is targeted by the Wellbeing
Programme. SAD absence has fallen slightly
again since last month, remaining below the May
19 level. MSK absence has risen slightly but
remains below the May 19 level.
Actions
• Engagement sessions have occurred and
Intranet information is now available detailing
the new ‘adjustment passport’ for staff
requiring work place adjustments;
• New ER (Case Management) Tracker to be
rolled out from August, which will allow more
robust tracking of sickness cases and issues;
• The wellbeing programme continues to grow
in awareness and usage. There has been a
steady and marked increase in take up of the
EAP. For example, in May 2019 there were
43 calls to the helpline and 23 face to face
counselling sessions, compared to 18 calls
and 9 counselling sessions in November
2018.
• 2 WTE Psychologists are being recruited
permanently to the programme and will start
in October 2019
• Our wellbeing programme continues to gain
recognition by winning a second national
award – the NHS Parliamentary Wellbeing at
Work Award.
Mandatory & Statutory Training
The Top 8 Statutory / Mandatory training topics continue to show their
sustained increase to the current 90%.
Leadership Development
The one NBT Leadership programme launched in June 2019 with the
delivery of the first core day. We are still taking nominations from
divisions and have over 300 participants which is 92% of our estimated
target of 350 learners in year 1.
Appraisal Completion
We are now into month 3 of the 2019 Appraisal window. Compliance with the
target population was 12% at the end of June 2019.
Equality, Diversity and Inclusion
To ensure there is no disproportionality in outcome and experience of certain
staff groups and to start understanding where specific focus should be given to
improvement, the IPR will now build a core set of workforce KPIs split by gender
and ethnicity. The KPIs will be appraisal, MaST training, sickness and turnover.
If identified gaps between female and male staff and BaME and white staff
increase disproportionately, further investigation will take place and appropriate
actions will be designed to address any underlying issues.
RN/RM CA Fill RN/RM CA Fill
Southmead 90.1% 94.2% 96.4% 105.0%
Day shift Night ShiftJun-19
The numbers of hours Registered Nurses (RN) / Registered Midwives (RM) and
Care Assistants (CA), planned and actual, on both day and night shifts are collated.
CHPPD for Southmead Hospital includes ICU, NICU and the Birth Suite where 1:1
care is required. This data is uploaded on UNIFY for NHS Choices and also on our
Website showing overall Trust position and each individual gate level. The
breakdown for each of the ward areas is available on the external webpage.
Wards below 80% fill rate are:
Quantock: 79.9% RM Days and 73.3% MCA nights. The unit has
a high number of STS and LTS and working with HR to resolve this.
To keep the people attending the unit safe the extended bed base
has been moved from Cotswold to Percy Philips, where there is a
constant midwife presence.
NICU: 74% MCA on nights. NICU have now fully recruited to MCA
roles, however some remained supernumerary in June. When there
is a gap if acuity dictates, this is covered by registered staff. If
acuity is low and number of babies is low then the shift is not
covered.
32B: 66.8% CA days. This is due to a template change in the ward
requirement for the NA role. The ward has been monitored through
leadership and flow to maintain safety.
MSS: 83% RN and 86.2% CA on days. The fill rate are due this
this being predominately an over night surgical recovery where
many patients leave in the morning therefore staff are moved to
support through the rest of Medirooms returning to support those
who need an extended stay in the area in the evening.
9A: 79.3% RN Nights. This is due to the vacancy on the ward. Shift
have been filled as required based on the A&D of the ward.
oversight has been maintained and reviewed for safety through
leadership and flow.
Gate 19: 67.8% CA days and 65% CA nights. This area is
reported as it has been open as escalation capacity for more than 3
consecutive nights. The fill rate is due to vacancy across the gate
which included the labs, the base template is currently under
review. The area will only admit patients to the number of staff
available and is being closely monitored to the SOP by the matron
to maintain patient safety.
Ward over 175% fill rate:
No ward were over 175% this month
Cossham
Remains closed to women and not reported externally.
Care Hours per Patient Day (CHPPD)
The chart shows care hours per patient
day for NBT total and split by registered
and unregistered nursing and shows
CHPPD for our Model Hospital peers (all
data from Model Hospital, peer values only
available to Feb 2019).
Safe Care Live
(Electronic Acuity tool)
The acuity of patients is measured three
times daily at ward level. The latest data
for March demonstrates there are
occasions the rostered hours do not meet
the required hours.
The Safe Care data is however
triangulated with numbers of staff on shift
and professional judgement to determine
whether the required hours available for
safe care in a ward/unit aligns with the
rostered hours available.
Staff will be redeployed between clinical
areas and Divisions following daily staffing
meetings involving all Divisions, to ensure
safety is maintained in wards/areas where
a significant shortfall in required hours is
identified, to maintain patient safety.
Medical Appraisal
The General Medical Council requires that all licensed doctors complete an
annual appraisal. The NBT system demonstrates that 100% compliance
was achieved in 19/20. The board will receive a full annual report in
September 2019.
To date in 19/20, 56% of the appraisals due have been completed. This is
reduced performance compared to previous years and is considered to be
due to implementation of the new Fourteen Fish appraisal software system
in March 2019. The issues related to implementation and user
familiarisation with the new software are being resolved and it is anticipated
that the appraisal delays will be recovered in year. A small number of
doctors who are new to the Trust do not yet know their appraisal dates and
this is more common in locum and clinical fellow grades which contributes
to the lower appraisal compliance in these groups.
The Trust has an active process for managing those who miss their
expected appraisal date. Persistent failure will lead to notification to the
General Medical Council (GMC) that the doctor is not ‘engaged’ with the
system.
The Trust has currently deferred 28% of all revalidation recommendations
due over the past 12 months. There are a number of legitimate reasons for
deferral but the relative increase in percentage deferred over the past 12
months is contributed to by the small overall numbers needing revalidation
in the final year of the five year cycle. From March 2019, the GMC will be
collecting further information for the reasons of each deferral.
In June 2019 a non-engagement recommendation was made for one doctor
who holds an honorary contract with NBT.
.
Finance
Board Sponsor: Director of Finance
Catherine Phillips
Plan Actual
Variance
(Adverse) /
Favourable
£m £m £m
Income
Contract Income 131.7 130.1 (1.6)
Other Operating Income 21.1 19.9 (1.2)
Donations income for capital acquisitions 0.0 0.0 0.0
Total Income 152.8 150.0 (2.8)
Expenditure
Pay (96.5) (95.2) 1.3
Non Pay (46.2) (43.9) 2.3
PFI Operating Costs (1.6) (1.5) 0.1
(144.3) (140.6) 3.7
Earnings before Interest & Depreciation 8.5 9.4 0.9
Depreciation & Amortisation (5.9) (6.3) (0.4)
PFI Interest (8.6) (8.6) 0.0
Interest receivable 0.0 0.0 0.0
Interest payable (1.3) (1.2) 0.1
PDC Dividend 0.0 0.0 0.0
Other Financing costs 0.0 0.0 0.0
Impairment 0.0 0.0 0.0
Gains / (Losses) on Disposal 0.0 0.0 0.0
Operational Retained Surplus / (Deficit) (7.3) (6.7) 0.6
Add back items excluded for NHS accountability
Gains on Disposal 0.0 0.0 0.0
Donations income for capital acquisitions 0.0 0.0 0.0
Depreciation of donated assets 0.0 0.2 0.2
Additional 2018/19 PSF bonus 0.0 (0.7) (0.7)
Impairment 0.0 0.0 0.0
Adjusted surplus /(deficit) for NHS accountability (excl PSF) (7.3) (7.2) 0.1
PSF / FRF / MRET 3.8 3.8 0.0
Adjusted surplus /(deficit) for NHS accountability (incl PSF) (3.5) (3.4) 0.1
Position as at 30 June 2019
Statement of Comprehensive Income
Assurances
The financial position at the end of June shows a deficit of £3.4m,
£0.1m favourable to the planned deficit.
Key Issues
• Contract income is £1.6m adverse to plan largely due to
under-performance in elective inpatient activity.
• Other operating income is £1.2m adverse to plan due a
number of factors including unachieved CIP which is likely to
recover.
• Pay is £1.3m favourable to plan reflecting substantive
vacancies offset in part by temporary staffing.
• Non pay is £2.3m favourable to plan mainly in clinical supplies
and drugs.
• The savings shortfall at June was £3.2m the impact of which
has been offset by a number of one-off benefits. The under
achievement of savings, if not recovered, represents a risk to
the delivery of the Trust’s control total.
Statement of Financial Position
Assurances
The Trust has received net new loan financing for the year to
date of £2.6m. This brings total borrowing from the
Department of Health and Social Care to £180.9m.
The Trust ended the month with cash of £10.7m, compared
with a plan of £8.0m.
Concerns & Gaps
The level of payables is reflected in the Better Payment
Practice Code (BPPC) performance for the year which is
68% by volume of payments made within 30 days against
the target of 95%.
Actions Planned
The focus going into 2019/20 continues to be on maintaining
payments to key suppliers, reducing the level of debts and
ensuring cash financing is available.
Rolling Cash Forecast, In-year
Surplus/Deficit, Capital Programme
Expenditure and Financial Risk Ratings
The overall financial position shows a £3.4m
deficit, £0.1m favoura
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